Welcome to the exciting world of ERISA! This blog is written by attorneys Kate MacKinnon and Sarah Demers at the Law Office of Katherine L. MacKinnon. Here, we'll talk about ERISA: updates on employee benefit law, information we hope people who have been denied benefits will find helpful, and any news or tidbits we think should be shared with the world.

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Monday, December 11, 2017

Denials for Experimental or Investigational Medical Services

A common reason health care claims are denied is that the service is experimental or investigational. Each health insurance policy defines "experimental" differently, but basically the health insurer is saying hat the treatment is not proven to treat the medical condition the patient suffers from.

These denials can be devastating because the patient may have already exhausted other treatment choices. She may have been told by her treating doctor that this particular treatment is the best one for her particular health condition. These are also very hard denials to overturn because what treatments are "experimental" is generally decided by the health insurer without having to defer to the treating doctor's opinion.CNN posted a recent article about individuals with serious seizure disorders who want to get ablation surgery - a minor brain surgery to treat lesions on the brain causing seizures. The alternative surgery is much more invasive and dangerous. Aetna, the health insurer for the individuals, denied the claims for ablation surgery, stating that it is experimental."The laser surgery is approved by the Food and Drug Administration and is widely recognized within the epilepsy community as an effective treatment alternative to open brain surgery, especially when the location of seizure activity can be pinpointed to a specific part of the brain. Dr. Jamie Van Gompel, a neurosurgeon at the Mayo Clinic, disputes Aetna's assessment. He is not involved in Cara's care nor Rittereiser's treatment, but he said Aetna's assessment is wrong."I would not call it experimental at all," said Van Gompel, who is leading a clinical trial on the surgery at Mayo as part of a larger national study. "It's definitely not an experimental procedure. There've been thousands of patients treated with it. It's FDA-approved. There's a lot of data out there to suggest it's effective for epilepsy."Read the whole article here: "Girl has blunt message for Aetna after her brain surgery request was denied"